Clinical and epidemiological profile of ST‐segment elevation myocardial infarction patients in a megacity of west of Iran

Abstract Background and Aims Low‐ and middle‐income nations account for at least three‐quarters of cardiovascular disease deaths worldwide. This study aimed to obtain real knowledge about ST segment elevation myocardial infarction (STEMI) patients and provide the context for developing a principles for care quality improvement. Method This cross‐sectional study was conducted from July 2018 through December 2019. The study sample consisted of1169 eligible patients based on inclusion criteria. The data were collected using the standard EROP and three specialized, trained questionnaires. The collected data were checked by the quality control officer and analyzed using Stata Version 14. Results Patient baseline characteristics showed that body mass index, low‐density lipoprotein, high‐density lipoprotein, total cholesterol, and triglyceride levels were higher in women. Also, females recorded a considerable history of diabetes mellitus, hypertension, and hypercholesterolemia compared to men. The results also showed that most men were smokers (46.80%). Aspirin (94.27%), statins (91.48%), and clopidogrel (90.68%) were the common medications used at hospital discharge for patients. Conclusion The present study suggests that identifying and managing modifiable risk factors can improve cardiovascular disease outcomes. Also, considering the early identification of STEMI patients with new therapies can effectively decrease the rate of cardiovascular disease and its attributed health outcomes.


| INTRODUCTION
According to the World Health Organization's (WHO, 2021) reports, around 17.9 million people died from cardiovascular diseases (CVDs) in 2019, accounting for 32% of all global deaths. Ischemic heart disease (IHD) corresponds to a significant share of causes and ranks as the most prevalent among these deaths. 1 In the interim, acute coronary syndromes (ACS) and sudden death cause most IHD-related deaths, representing 1.8 million deaths per year. 2,3 ACS refers to patients with suspicion or confirmation of acute myocardial ischemia or infarction. ACS is classified into three traditional types, including non-ST-elevation myocardial infarction, ST-elevation myocardial infarction (STEMI), and unstable angina, in which STEMI is a more common type of heart attack. 4 A STEMI is the most severe heart attack because it obstructs one or more coronary arteries, and blocks blood flow to the heart. STEMI can result in more long-term heart disease and increase the risk of death in patients in the short term. 5,6 Low-and middle-income nations account for at least threequarters of CVD deaths worldwide. People in low-and middleincome nations have less access to primary health care for the early detection and treatment of CVDs. Therefore, disease detection is frequently delayed in these countries, and people die from CVDs and other noncommunicable diseases at a younger age, typically during their most productive years. 7,8 In Iran, a few decades ago, the most prevalent causes of death transitioned from infectious disease to CVD. According to the Global Burden of Diseases reports (2010,2015), CVD was the first leading cause of mortality and DALYs, so it was responsible for 46% of all deaths and 20%-23% of the burden of diseases in Iran. 9,10 According to a review of studies from the previous 40 years, IHD and stroke are the leading causes of death and DALYs in Iran. 9 Another study predicted that the burden of CVD in Iran will rise sharply between 2005 and 2025, with CVD DALYs rising from 847,309 in Iranian adults in 2005 to 1,728,836 in 2025. 11 The rising CVD epidemic could be linked to socioeconomic and cultural changes, an increase in smoking and dietary changes, insufficient physical activity, industrialization and urbanization, rising life expectancy, rising metabolic and physical risk factors, low access and affordability to primary care and treatment, and low compliance due to economic and psychological issues. 9,10 The results of studies show that there is an urgent need to focus on implementing existing cost-effective policies and interventions to reduce disability and premature death due to CVD. Meanwhile, cardiovascular registries by providing real-time data on a variety of cardiovascular disorders and allowing for the analysis of quality measures across a broad group of patients help to measure and improve the quality of care and are also useful for the development of treatment protocols, and identification of risk factors. Therefore, a registry was conducted in the heart center of megacity in the west of Iran from July 2018 to December 2019. The present study area is Kermanshah Province, Iran, and according   to the 2016 census, its population is 946,681 (2021 estimate: 1,047,000). Kermanshah is a largest and most central city, located in the middle of the country's western part. This study was conducted in Imam Ali Hospital, which is the first center of cardiovascular surgery and angiography, and the quality and quantity of diagnostic and

| Measures
The data were collected by the standard EROP questionnaire and three specialized trained questionnaires. The questionnaire was administered in three stages, including: (1) upon arrival, (2) after the patient's condition stabilized, (3) during discharge and afterward by trained questioners who were stationed in the hospital (where the myocardial infarction [MI] patient was hospitalized). Interviews were conducted with the patient or his/her companion as soon as possible so that the treatment process was not disrupted. However, data collection related to anthropometric measurements, nutrition, physical activity, diagnostic-therapeutic measures, in-hospital accidents, and medication use was completed after the patient was transferred to the ward and his clinical condition stabilized. The results of tests, echo, and other measures in the paraclinic were extracted from the patient's file. One year after diagnosis, the subjects were referred to the hospital for re-examination and echo and other tests.
First, the purpose of the survey was communicated to all participants and they will be assured that the data will be kept confidential.

| Statistical analysis
The collected data were checked by the quality control officer and analyzed using Stata Version 14. Table 1 summarizes the demographic characteristics of the study population. The mean (SD) participant's age was 60.65 (12.26) and the mean age of women 65.24 (11.42) was higher than that of men 59.43 (12.19). Most of the participants' educational level was illiterate or in primary school, and the share of illiterate women was higher than the rest. Also, a large percentage of the study population were Kermanshah citizens.

| RESULTS
Patient baseline characteristics are presented in Table 2. Hemoglobin, white blood cell, platelet (PLT), creatinine, and glomerular filtration rate mean values were higher in males than females. In contrast, body mass index, low-density lipoprotein, high-density lipoprotein, PLT, total cholesterol, and triglycerides are higher in women.
The medical history of the study population is presented in showed that a significant percentage of men were smokers (46.80%). Based on Table 3, significant statistical differences were observed between men and women for a history of MI, a history of PPCI, history of angina, DM, hypertension, hypercholesterolemia, and being a current smoker.
The medications used at hospital discharge for patients are reported in Table 4. A total of 94.27% of patients received aspirin 90.68%, received clopidogrel, and 91.48% received statins. Also, significant statistical differences were observed between men and women for MRAs.

| DISCUSSION
The present study was conducted as a cardiovascular registry by providing real-time data on STEMI in the heart center of a megacity in the west of Iran. According to the study's findings, the mean (SD) age of women was 65.24 (11.42), while men were 59.43 (12.19). The results of other studies that considered patients with STEMI, show that women were older than men, for example, in Lina et al. 13 study, women were older (69.8 vs. 63.2 years; p < 0.001) and in the Zachura et al. 14 study, women were also older than men (72.0 ± 11.3 vs. 64.0 ± 11.7 years; p < 0.0001). 13 Other results of the present study in Hispanic women. Alos, women underwent fewer invasive cardiac procedures compared with men, including reperfusion, right heart catheterization, and mechanical circulatory support. 13 The higher prevalence of some variables in women can be explained by hormonal changes, for example, affecting how their bodies use insulin, which puts them at a higher risk of developing diabetes and also blood pressure can be affected by weight gain.
The same finding was also reported in other studies. [15][16][17] Furthermore, in the study that described the sex-based differences in DM in a low-income population in China, the prevalence of DM was 14.1% in men and 14.5% in women.
The results of the present study showed that a history of MI, CABG, angina, PPCI, stroke, and smoking was more prevalent in men than women. The results of the study are consistent with other studies that reported women were less likely to have undergone prior PCI and to have known coronary artery disease. 13 As the effects of many risk factors can be changed, it seems management of modifiable risk factors can improve cardiovascular disease outcomes. aged 40-64 years projected to be at greater than 20% risk ranged from less than 1% in Uganda to more than 16% in Egypt. 18 The results showed aspirin (94.27%), statins (91.48%), and clopidogrel (90.68%) were the common medications used at hospital discharge for patients. It seems the rate of aspirin prescription is high, however, it is comparable, or higher than other studies. In many other studies also, the rate of aspirin prescription was high. 19 The limitations of our study are as follows: (1) Some individuals with acute MI may not be able to participate in the study interview due to their health condition. So, the patient's family was asked, with the patient's approval, to give the necessary data about the patient, and if the patient's answer were necessary, the data were gathered when the patient's health state was stable. (2) Loss to follow up, to address this limitation, participants were asked to notify the researcher of any changes to their contact information or address.
Throughout the recruitment phase, at least three contacts information from the participant's family was documented. Another strategy for reducing loss to follow-up was to provide participants with free medical services as well as information about the significance of the research. Also, if a patient is unwilling to come to the hospital for the follow-up appointments, follow-up information will be gathered as much as possible through a home visit or a phone interview. In addition, the health information system of the hospital will also be utilized to monitor patient readmissions during the research period and the death record department will be contacted to confirm a participant's death.
T A B L E 2 Patient baseline characteristics (mean ± SE).